The Bane of Back Pain

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The Bane of Back Pain

• Nancy Rodway MD MPH
• Medical Director Occupational Services
• Lake Health
• Medical Director LCGHD

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Objectives

• Describe the scope of the problem
• Anatomy 101
• Understand the anatomy of back pain
• Can anything prevent back pain?
• How to treat back pain?
• Can anything predict back problems?
• Recommendations for employers

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Back Pain Basics

• 60-80 of adults will experience LBP
• LBP more days off work than any occupational
  injury
• LBP 10-33 of BWC costs
• 90 of LBP resolves within 90 days even without
  any treatment
• Often no clear-cut cause for pain

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Anatomy 101
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Disc disease

• Common by age 40
• 80 of 60 year olds have bulging discs

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WARNING!

• Cancer
• Fever
• Incontinence
• Pain not relieved by rest

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Metastatic Cancer
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Epidural Abscess
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Abdominal Aortic Aneurysm
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Occupational Back Pain
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Evaluation of OTJ Back Injuries

• Waddell Signs
• Tenderness tests superficial and diffuse
  tenderness
• Simulation tests axial loading
• Distraction tests
• Weakness or sensory changes which arent
  anatomically logical
• Overreaction

Need 3
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Evaluation Continued

• Symptom Magnification
• Non-physiologic Symptoms

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None for six weeks
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Treatment for Acute LBP

• Heat
• OTC analgesics
• Manipulation
• Aerobic activity
• Harpagoside
• Massage
• Fear avoidance behavior testing and training

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Clinical Prediction Rule

• Fear Avoidance Behavior

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Fear Avoidance Training
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Harpagoside
DO NOT TAKE WITH BLOOD THINNERS
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What doesnt work in acute LBP

• Antidepressants
• Routine use of opiates
• Dietary supplements
• Lumbar supports
• Mechanical massagers

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What doesnt work in acute LBP

• Traction
• Myofascial release
• Acupunture
• Stretching
• Prolotherapy

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NO BED REST!!!!
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What works for chronic LBP

• Heat
• Massage and acupuncture for short term
• TENS units
• Aerobic exercise and strengthening
• Yoga
• Trigger point injections
• Cognitive behavioral therapy
• Back school

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What works for chronic LBP

• OTC analgesics
• Opiate trial IF function improves
• Harpagoside
• Alteration of sleep posture (NOT mattress)
• Neuroreflexotherapy
• Shoe insoles
• Heel lift if leg length difference

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Sleep
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Neuroreflexotherapy
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What doesnt work for CBP

• Regular or routine manipulation
• Strengthening abdominal muscles
• Spinal injections if no leg pain (epidural or
  facet)
• Prolotherapy

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What doesnt work for CBP

• Surgical lumbar fusion
• Artificial disc replacement
• Spinal cord stimulators
• Discectomysurgically trimming the bulging disc

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Does surgery help?

• Simple lumbar discectomy for leg pain x 4-6 weeks
• Decompression surgery for spinal stenosis
• Fusion for spondylolisthesis
• SURGERY TREATS LEG PAIN/WEAKNESS

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Medicalization of Back Pain

• Patients need reassurance that most back pain is
  benign and 90 resolve without treatment
• Getting a specific DIAGNOSIS suggests there is a
  CURE leading to
• Failed expectations
• I just want them to fix me.
• Problem with BWC
• Abnormal findings on Xray and MRI are normal by
  age 40 and 80 of adults have abnormal Xray/MRI
  by age 60

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CURE often not possible

• Focus on return to prior function
• Limit focus on PAIN in recovery

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Back pain preventionWhat works

• Core strengthening
• Proper lifting technique
• Ergonomic stations
• Engineering controls
• Smoking cessation and weight loss

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Back pain preventionWhat does not work

• Back Class/School
• Back Brace
• Stretching

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Screening tests for back injuries

• Can you avoid hiring workers who will be injured?

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Xrays of the lumbar spine do not predict
occupational back injuries and may harm the worker
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Predictive of LBP

• Physical exams dont predict LBP
• Lift tests predict only the weakest worker
• A history of back problems predicts LBP
• Family history of LBP predicts LBP
• GINA law means you cannot ask family history
• Job Performance Assessment

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Job Performance Assessments
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Recommendations

• Prioritize ergonomics and engineering controls to
  prevent back injuries
• Consider on-site manipulation
• Consider JPAs
• Maintain a healthy workforce
• Do not hire smokers or encourage smoking
  cessation
• Assess fear avoidance behaviors and be aggressive
  with claim management if high

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American College of Occupational and
Environmental Medicine Practice Guidelines
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The End